CHERRY STREET HEALTH SERVICES
CONSENT TO THERAPEUTIC PROCEDURE, ANESTHESIA, OTHER SERVICES
1. PROCEDURE
I consent to have the insertion of the INTRAUTERINE COPPER CONTRACEPTIVE (IUD) a reversible form of pregnancy prevention, performed on
______(Name of patient)
at Cherry Street Health Services by______(Name of provider) and his/her designated assistant.
I have read the IUD brochure in its entirety and discussed its content with my provider. My provider has answered all my questions and has advised me of the risks and benefits associated with the use of the IUD, with other forms of contraception and with no contraception at all.
The IUD insertion will be by guiding a narrow inserting instrument through the opening of the cervix into the uterus. When it is time to remove the IUD my provider must remove it.
Unplanned pregnancy rate of users over twenty years old is 99%. I understand that any procedure has definite risks of complications and no guarantees have been made to me about the possible results that may be obtained from this procedure.
2. RISKS/SIDE EFFECTS
The following risks/side effects may occur while the IUD is being inserted and while it is in place
a. This product is intended to prevent pregnancy. It does not protect against HIV infection (AIDS)
and other sexually transmitted diseases.
b. Pain or cramping during or following the procedure. If pain or cramping is severe, becomes worse, or persists, contact your provider.
c. Fainting may occur at the time of insertion or removal of the IUD.
d. Bleeding may occur.
e. Partial or total perforation of the IUD through the wall of the uterus may occur at the time of, or after, insertion. If you think the IUD is displaced, check with your provider. Perforation could result in abdominal adhesions (scars), intestinal obstruction or penetration, inflammation, serious infection, and loss of contraception protection.
f. Bleeding between menstrual periods may occur during the first 2 or 3 months after insertion. The first few menstrual periods after insertion may be heavier and longer than usual. If these conditions continue longer than 2 or 3 months, consult your provider.
g. Occasionally, you may miss a miss a menstrual period while using the IUD. It is important to determine if you are pregnant; report this to your clinician.
h. The IUD may come out of your uterus through the cervical opening. This is called expulsion, and is most likely to occur during the first 2 or 3 menstrual cycles following insertion. Expulsion leaves you unprotected against pregnancy. If you think the IUD has been expelled use another form of birth control, such as contraceptive cream, vaginal foam or jelly, or condoms (rubbers), until your provider can check you.
3. CONSENT
My signature below means: 1. I am aware of the reasons for the procedure and have been informed of the risks and complications; 2. I have been informed of the possible alternatives to the procedure; 3. I have had an opportunity to have my questions answered and received satisfactory answers; and 4. I have read and agree to the above and hereby consent to the procedure.
Patient’s Signature______Date______
______Relationship______
Signature of parent or guardian of minor patient or guardian of incompetent patient
Witness______
Provider ______
Lot Number and Expiration
5/00
CHERRY STREET HEALTH SERVICES
CONSENT TO THERAPEUTIC PROCEDURE, ANESTHESIA, OTHER SERVICES
1. PROCEDURE
I consent to have the insertion of the NORPLANT CONTRACEPTIVE (a reversible form of pregnancy
prevention) performed on ______(Name of patient) at
Cherry Street Health Services by ______(Name of provider) and his/her designated assistant.
I have read the Norplant information form in its entirety and discussed its content with my provider. My provider has answered all my questions and has advised me of the risks and benefits associated with the use of the Norplant System, with other forms of contraception and with no contraception at all.
The Norplant System is a time-release, subdermal (implanted under the skin surface) contraceptive method that provides protection from pregnancy for as long as five years. Six flexible capsules containing the hormone LEVONORGESTREL are inserted one at a time under the skin in a fan-shaped pattern.
The Norplant System’s effectiveness rate is less than 1% of women using Norplant become pregnant over 5 years of use. I understand that any procedure has definite risks of complications and no guarantees have been made to me about the possible results that may be obtained.
When it is time to remove the Norplant capsules my provider must remove it.
Norplant does not protect against HIV or Sexually Transmitted Diseases.
2. ANESTHESIA
I understand that the procedure requires Local Anesthesia. The risks, though rare, include allergic reactions, heart rhythm disturbances, seizures and or death and these have been explained to me. I consent to the administration of anesthetic and supportive measures under the direction of
______(Name of provider) and to use such anesthetic/s
he/she may deem necessary with the exception of______.
3. CONSENT
My Signature below means: 1. I have read the information on this form, which describes the Norplant System, and verify that I have received a booklet giving additional information. 2. I am aware of the reasons for the procedure and have been informed of the risks and complications; 3. I have given my medical history to the best off my knowledge in relation to the use of the Norplant System; 4. I have had an opportunity to have my questions answered and received satisfactory answers; 5. I have read and agree to the above and hereby consent to the procedure.
Patients Signature______Date______
______Relationship______
Signature of parent or guardian of minor patient or guardian of incompetent patient
Witness______
Provider______
Lot Number and Expiration
(Rev. 5/00)